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CPP Demographics
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PATIENT'S NAME *
Patient Date of Birth: *
MM
/
DD
/
YYYY

"What is your current gender identity?"

"What sex was assigned to you at birth?"

 *
Home Address: *
Mobile Phone Number: *
Number to call incase of Office Closure/Provider out: *
E-Mail Address: *
Marital Status:
If Patient is a child please list their year in school:
Pharmacy: (name, address and phone number) *
Referred by:
We seldom have a medical student accompanying our providers as part of their training; would you be comfortable if a medical student observed your session with your doctor or clinician? They will be silently observing and learning. Your consent is completely voluntary. *
I hereby agree to pay any and all charges, fees for the appointments and charges due to a missed appointment with less than a 48 hour cancellation.  (Answer yes; Type full name and date below) (Parent or Guardian please sign for underage patient) *
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